Thursday, August 30, 2007

I saw this abstract and wanted to post it. Entitled Psychiatrist Attitudes toward Self-Treatment of Their Own Depression, it's a survey conducted of Michigan psychiatrists regarding their opinions toward self-prescribing. A survey of more than 500 Michigan psychiatrists showed that more than 40% would medicate themselves for mild to moderate depression and that 15% had actually done so in the past. Seven percent of psychiatrists said they would treat themselves for severe depression or depression involving suicidal ideation.

The AMA code of medical ethics states: "Physicians generally should not treat themselves or members of their immediate families...It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems."

So why or when would a doctor consider treating himself? I don't know Michigan well, but I'd guess they probably have the same shortage of psychiatrists that other Midwestern states have. If you're a depressed psychiatrist you may be the only game in town. Maybe he'd be concerned about privacy and information-sharing among colleagues.

Or maybe the AMA would consider mild clinical depression to be a "short-term, minor problem" for which the self-treatment exception would apply. There are probably hundreds of physicians who at one time or another have written antibiotic prescriptions for themselves or for family members. I wonder if this also applies to prescribing for family pets? Should a psychiatrist prescribe Prozac for his obsessional cat? Thorazine for the nervous dog? A recent survey of neurologists showed that more than 90% agree that it would be appropriate to self-prescribe for acute minor illnesses. Another survey of young Norwegian physicians found that 90% had self-prescribed in the past year.

Wednesday, August 29, 2007

The Girl with the Blue Stethoscope has a post today (Why Is It So?) about how psychiatrists are the most interesting lecturers. She has great tastes, huh?

...I have noticed that psychiatrists as a group tend to give the most interesting and engaging lectures of all. Their voices are very natural and conversational in tone even as they lecture on academic topics, their communication skills are excellent, they look relaxed, and of course, they tend to have fantastic (yet anonymous) anecdotes.

I have noticed that medical students as a group tend to have the most insightful blog posts :-)

This week's theme is Narrative Medicine. Pioneered by Rita Charon, an internist and professor at Columbia's College of Physicians and Surgeons, Narrative Medicine trains doctors and other caregivers to use careful listening and reflective writing to forge deeper connections with their patients, resulting in better care.

Charon describes three essential components of narrative medicine:

Attention: Listening carefully to patients, which includes remaining sensitive to what they may not be saying, gives the caregiver potentially valuable information and also makes the patient feel more cared for.

Representation: Using writing to reflect on patient interactions helps caregivers understand both their own feelings and those of their patients more deeply.

Affiliation: The process of attending carefully to patients and reflecting on patient stories ultimately makes caregivers stronger and more passionate patient advocates, because they've become more invested in their patients' care.

Tuesday, August 28, 2007

I was surfing the NY Times website and came across this article by Ronald Pies, a psychiatrist in the Boston area. Dr. Pies talks about a wonderful nurse he worked with in the psychiatric emergency room and his surprise when he walked on to the inpatient one morning to find this same wonderful nurse, now admitted as a patient with a severe major depression. Dr. Pies talks about wanting to save his colleague, and recounts how over the course of an 8-week admission, the patient's symptoms didn't respond to two different anti-depressants. He later runs into the patient, now cured of his atypical depression by an outpatient doc who recognized his atypical symptoms and more appropriately treated the patient with an MAOI (an older type of anti-depressant). Dr. Pies laments that he missed the diagnosis because the patient was a VIP of sorts, that he didn't get approached in the same way, with the same freshness and thoroughness, that a stranger would be, and he refers to Jerome Kroopman's book, How Doctors Think, as a reference for the celebrities-get-worse-care phenomenon.

We've talked about these issues here at Shrink Rap, asking whether docs as patients fare worse, and we even discussed a New Yorker article by Dr. Kroopman a few months ago. Here at Shrink Rap, we do it all.

I thought: I should write a blog post about this NYTimes piece. There's a lot to write about-- we could talk about Atypical Depression, missing diagnoses, the use of MAOIs in treatment today, treating people we know. Oh but it's August, I'm feeling lazy, I let it go. And then today, I was reading Clinical Psychiatry News, kind of psychiatry's version of a tabloid, and I saw a letter by the same Dr. Pies. He wrote to discuss how the term "Shrink" is demeaning, how we shouldn't use it. This, of course, inspired me to write this post, I'm still not sure what it's about.

There are some words that feel very powerful, some that squeeze me. Shrink isn't one of them (obviously). I don't generally refer to myself as a shrink--- except in Shrink Rap posts where it flows out pretty easily-- but when others do, I don't cringe. If it's supposed to be a derogatory term, demeaning, hurtful or vengeful, laden with stigma and rife with belittlement of my chosen profession, none of that has jelled in my heart. The term evokes nothing in me, it's not what I feel when I hear people utter racial or religious slurs. Should it be? Did I miss something big? I know Roy isn't nuts about the term "shrink." ClinkShrink, I'm guessing, has incorporated the word as part of her internalized identity.

I don't know Dr. Pies. I wonder if he'd like Shrink Rap, of if he'd just cringe at the title, shun the three psychiatrists who use a derogatory term so lightly, ducks and all. Gosh, are we just a bunch of quacks?

Monday, August 27, 2007

Dinah sent me this link to a New York Times article about Robert Sillen, a former hospital administrator appointed to reform the California prison medical system. I know FooFoo5 has opinions about medical care in California prisons so I defer to his experiences there. I'm just here to think about change and how this is accomplished.

The Times article makes a point of highlighting Mr. Sillen's brash, at times profane, change-at-all-costs political incorrectness. As a Federally appointed health care receiver he has been put in charge of recreating the correctional health care system and he has threatened to break the bank to do it. Right off the top of my head, I have several thoughts about this.

My first thought is that I think I would like this guy. A straight-shooting administrator---even a profane one---would be a relief from the polished political bureaucracy that grinds ever-so-slowly and ineffectively. If he can get things accomplished by being that way, more power to him.

My second thought is that he probably won't last very long. Bureaucracy punishes efficiency, particularly when it's carried out without proper obeisance to the powers-that-be.

My third thought was triggered by this passage: "Mr. Sillen, whose $500,000 annual salary puts him among California’s highest paid public officials, said he had never visited a prison or thought much about the penal system until a recruiter called last year to persuade him to accept what the recruiter called a “mission impossible."

The man charged with reforming correctional health care has never been inside a prison. When he visited a penitentiary he was surprised to find "no sinks, no phones, no faxes, no way to communicate, no nothing". What? No phone? I'm shocked! Shocked, I tell you! As they used to say in the old Lost In Space show: "Danger, Will Robinson!" He is not a clinician, nor does he have correctional experience. Does anyone besides me think this is a bit odd? What were the Feds smoking? I hope he has clinical and correctional advisors he will listen to.

On the positive side, he's stating the obvious that everyone in free society needs to hear. He criticizes "tough on crime" policies that don't take into consideration the demand for health care services that these policies require. On the correctional administrative side, he criticizes prison officials who build new facilities without regard for treatment infrastructure. These are obvious things that need to be said loudly and repeatedly so no one forgets.

Friday, August 24, 2007

It's August and I'm back in town. Psychiatrists are notorious for taking vacation in August, I hear they all go to Wellfleet. Sounds wonderful.

Back in Baltimore, I'm covering for a vacationing psychiatrist who often covers for me. We've cross-covered for years and I've handled just a few emergency calls, but quite a number of prescription refills.

They never teach you in medical school or residency the exact right way to handle writing prescriptions for patients of other docs while they're away, or if they did, I missed that class. People do what they're comfortable with and I have my own standards. If you'll remember from my post Covering Your...some time back, another doc (not the one I usually cross-cover with) once insisted on meeting with one of my patients before he would okay a refill on a medication-- it was a med she'd been on for years, and not a controlled substance, so I was surprised that he didn't just authorize the refill over the phone.

So it's August, and my phone rang today with a request: I'm Dr. Wellfleet's patient and he's away and I'll be out of meds tomorrow. Why, I think, does the patient wait until the day before they're out of medicine? This happens all the time. Now the confounding factor here is that Dr. Wellfleet prescribes controlled medications more often then I do, specifically stimulants to treat Attention Deficit Disorder, sometimes in high doses, that I don't generally feel comfortable prescribing. These medications, in Maryland, can not be refilled or phoned in and the prescription can't be faxed. The patient must present a hard copy of the script each month to the pharmacist, so the patient's request the day before creates a number of issues for me: first I'm left to decide if I'll prescribe a controlled substance to a patient I haven't examined, and I have to ask if it's even reasonable to insist on examining a patient I'm cross-covering for particularly on a day's notice when I likely don't have an appointment --or if I do, what if the patient can't meet at the precise time I can? Or what if I meet with the patient and don't agree with the diagnosis and treatment-- is it reasonable to take a patient off a medication their regular doc, a well-respected and experienced psychiatrist, is prescribing anyway, and if not, then what's the point of meeting with them anyway? And what about the time I got a call from a patient out-of-state requesting a medication I would never feel comfortable prescribing-- she insisted Dr. Wellfleet's been prescribing it for years, the pharmacy verified this, the patient was hours away, and if I refused, the patient would go into a withdrawal which would require a hospitalization to manage. Oy.

Mostly, I deal with cross-coverage medication requests by phoning the pharmacy and verifying that the patient has actually been maintained on the medication by the regular shrink, that the medicine really does need to be refilled, that everything is kosher. If I can phone it in, I do. If it's a controlled substance, I authorize enough to hold the patient until their regular doc returns. If it needs a hard copy prescription, I do my best. If the patient calls on a day's notice, and I'm not scheduled to be in the office that day, they're out of luck --you can skip doses of stimulants without getting sick. I suppose I feel a bit like the patient is turning their disorganization into my emergency and when I'm sitting on hold with the pharmacy, negotiating times the patient can pick up the script, or feeling a little uneasy about writing for a specific med, I'm left to wonder if there isn't either a more efficient or more sanctioned way of doing this uncomfortable task without causing people to simply go without their meds, offending the doc I'm covering for, letting the patients risk relapse, or insisting on seeing the patients,with all the muck of what if I don't agree with the treatment and how will I squeeze them into my schedule.

Here's another interesting knockout mouse model for schizophrenia. This was in the July 31 issue of Molecular Psychiatry, "Phospholipase C-1 knockout mice exhibit endophenotypes modeling schizophrenia which are rescued by environmental enrichment and clozapine administration," by McOmish et al., in Australia.

"Phospholipase C-1 (PLC-1) is a rate-limiting enzyme implicated in postnatal-cortical development and neuronal plasticity. PLC-1 transduces intracellular signals from specific muscarinic, glutamate and serotonin receptors, all of which have been implicated in the pathogenesis of schizophrenia. Here, we present data to show that PLC-1 knockout mice display locomotor hyperactivity, sensorimotor gating deficits as well as cognitive impairment. These changes in behavior are regarded as endophenotypes homologous to schizophrenia-like symptoms in rodents. Importantly, the locomotor hyperactivity and sensorimotor gating deficits in PLC-1 knockout mice are subject to beneficial modulation by environmental enrichment. Furthermore, clozapine but not haloperidol (atypical and typical antipsychotics, respectively) rescues the sensorimotor gating deficit in these animals, suggesting selective predictive validity. We also demonstrate a relationship between the beneficial effects of environmental enrichment and levels of M1/M4 muscarinic acetylcholine receptor binding in the neocortex and hippocampus. Thus we have demonstrated a novel mouse model, displaying disruption of multiple postsynaptic signals implicated in the pathogenesis of schizophrenia, a relevant behavioral phenotype and associated gene–environment interactions."

PLC-1 is one of those proteins involved in processing the signal after the receptor is activated. Think of the ignition in your car. If the key is the neurotransmitter, like serotonin (or medication, like Prozac) and the lock (or keyhole) is the receptor, then PLC-1 is one of the wires that connects the lock on the steering column to the starter, which gets the engine going. We are all so used to thinking that what is important is the action at the receptor, but it is easy to forget that there is this whole other layer of machinery that gets engaged once the receptor is activated.

These so-called second messenger systems use a cascade of Rube Goldberg connectors to make things happen. Just like a genetic error can cause a receptor to malfunction, so can errors in this second messenger cascade.

This particular enzyme is involved in the growth and connectivity of brain cells. The researchers show that mice who are engineered to not produce PLC-ß-1 develop cognitive problems which have similarities to those seen in humans with schizophrenia. Changes in the environment can minimize these problems, suggesting that this animal model could be used to test other treatments -- including medications that work very differently from what is out there now -- for potential use in this neurodevelopmental illness.

Tuesday, August 21, 2007

Here is the little "podette" I mentioned last time. The next podcast, which will come out in the next day or so, features a special guest, Doctor Anonymous.

August 20, 2007: #31 Biteproof Gloves

Topics include:

Q&A: from Midwife with a Knife: Short version: How would you manage an agitated, aggressive patient in your OB/GYN office?

[Okay, here's the long version: Let's say I have this patient who's clearly distressed and obviously psychotic (if I can tell, it's pretty obvious) who's caretaker reports that they're seriously considering hurting themselves or others, clearly the patient needs to be sent to the psych ed/crisis center/whatever hospital equivalent for evaluation by an actual mental health provider... So, after the caretaker says to us, "I'm worried about taking her back to the group home, I'm think she's planning to hurt someone there.", and I talk with the patient who says something to the effect of, "I know that woman's planning to take my baby, and I'm going to hurt her before she gets the chance." I make the decision that she needs to be emergently evaluated. I try to talk her into going voluntarily (mostly by saying things like, "You seem pretty upset, I think it might help if you went and talked with the doctors downstairs", she refuses, and security is called to escort her down to the psych ed. Eventually, (I think triggered by the stress of that situation and the chaos of a busy clinic and the security officer's arrival), and in an attempt to leave the room (I happened to be sitting between her and the door), she kind of half tackled/half grabbed/half pushed me (Maybe to push me out of the way? I think she was just trying to leave. I don't think she was really trying to hurt me), the security officer grabbed her, she bit him (although he was wearing biteproof gloves) and she eventually was taken to psych. My question for you guys is, how do you psychiatrists recommend those sorts of situations be handled?

So, we answer the question in the podcast. We also speculate about "bite-proof gloves."

Oh, and if you want to see a funny but very strange rendition of Zappa's Peaches and Regalia -- with a man using his ungloved but cupped hands as a musical instrument -- then do check out this YouTube video (turn down your volume first). I could not stop laughing.

Monday, August 20, 2007

This isn't a post about psychiatry. Pretend you don't know I'm a shrink. This is a post by an old person ranting, most specifically by the mother of teenagers, ranting.

It's Fun Until Someone Gets Hurt, Then It's Hilarious

I saw that on a T-shirt recently, and actually the T-shirt was being worn by someone my age, the father of two teenagers. It pictured a skier stick figure, upside down, and I cringed-- why is it fun to watch someone get hurt? Why would someone make a T-shirt advertising that, and why would another someone buy it and wear it in public? I don't get it.

I grew up in a world where it became very important to be sensitive to others, to be conscious of what one says in terms of race, religion, nationality, gender. Words are important and if you utter the wrong ones, even innocently, you can be minced. I grew up in the North, post-Civil Rights, and attended integrated public schools and gender-balanced institutions of higher learning. Obscenities were bleeped on TV and Clarence Thomas was on trial for sexual harassment. My world started in a sensitive place, it's grown even more so.

Suddenly, it feels like the pendulum has swung the other direction-- a complete reaction to interpersonal sensitivity. I've entered (somewhat involuntarily, but hey, I had them) the world of teenagers. Words that have always been so powerful and negative, well, suddenly they're terms of endearment. I borrowed an iPod the other day to jog with-- Golly Gee, Wally-- 1800 downloaded songs and they each consisted of the same three obscene words chanted over and over. All I can figure is this culture irreverence-- perhaps best personified by the ugly and inept words of Don Imus-- is a cultural backlash to a world where being politically correct has become so important, so hammered into us.

I read an article not long ago in the Baltimore Sun-- it was about an entrepreneurial young man whose InternetT-shirt business had taken off. What an industrious young man. I went to the website, curious. Here's one of the shirts he sells:

You get the idea.

Mostly, the teenage world seems to have some feel for when and where-- they utter the unthinkable words and phrases amongst themselves, they understand (or so I'm told) their own code-- they keep this world hidden, and well they should. I may be wrong, but the rules all seem fuzzy as to who can say what to whom, where and when. Probably, and I may just be old, Mr. Brady, it would be fine if T shirts didn't announce the insensitivity of the wearer.

The good news is that I found some Led Zeppelin tunes on the iPod. There's still hope.

Friday, August 17, 2007

So I want to talk about some of the stuff going on in the comments section of Shrink Rap: if you haven't been reading along as we rant, it's gotten pretty heated. I'm not sure I can get this line straight as it's gone through a number of posts, but let me try.

Lily commented on Roy's post that she's angry that he's supporting an anti-psychiatry activist by linking to her. I have to admit, I sort of wondered about that one, too, but I assumed Roy liked an isolated part of the blog, and who says we have to agree with all the views of everyone we link to?

So here at Shrink Rap, we get a fairly diverse group of commenters: some love psychiatrists, some hate psychiatrists, and oh, some have a love-hate relationship with psychiatrists, psychiatry, and the whole concept of mental illness.

My feelings? Not that anyone asked, but here's what I think. Please remember that I don't work in any setting where I see anyone against their will--I'm an outpatient doc and my patients walk in the door willingly and walk out the door willingly. I'm here if you want and need me, very few exceptions.

I believe that if someone is suffering and wants the help of mainstream psychiatry, they should get it. Maybe they don't, or maybe psychiatry has failed them-- either because they saw the wrong doc, were given the wrong meds, had the wrong kind of therapy, or had a resistant problem that just didn't get better with the right therapy and numerous trials of the right meds with the right therapy. Psychiatric treatments help a lot of people, clearly they don't help everyone.

If someone wants to go it on their own or try alternative treatments: great. I'm not the person to see to obtain those remedies, although I am usually happy to treat my patients with conventional treatment while they also do yoga or have acupuncture, or even go to a faith healer, have their bowels cleansed, speak with their clergyman, or do anything else they think might help. I believe in what works-- if it helps someone, I'm all for it, with the exception of illegal drugs, but hey, I treat plenty of folks who use those, too, I just don't condone it.

Still, I don't like Anti-Psychiatry Activism and this is why. If psychiatric treatment didn't help a given patient, if the given patient even felt harmed by it, then perhaps that particular patient feels better served by another form of treatment or self-help. The problem with the activist part is that it becomes judgmental, it makes the case that others shouldn't seek psychiatric care-- that they are somehow wrong, weak, or flawed if they want to try conventional treatments or even if they feel helped by them. Anti-psychiatry activism enhances the stigma associated with psychiatric illness and treatment and serves as a deterrent to those who are seeking relief from their suffering.

If it helps, do it. And as someone who's back had back pain for the past 10 days, rest assured that it's part of the human condition to say to someone else: This Helped Me, Maybe It Will Help You. But don't condemn those who find help in a different place than you did.

Note to Jayme: I have not read your blog, this isn't a personal attack, just the springboard for a post inspired by Lily's distress.

So we are back from vacations and stuff. We had two podcasts we recorded before we took our relative hiatus, and this is the first of them. I plan to get the next one out over the weekend.

August 17, 2007: #30 Parity Feels Like a Bird

Topics include:

Mental Health Insurance Parity Legislation. 20-minute discussion about some of the current legislation (mind you this was recorded before the revisions made in early August to SB 558). Go to this link to see recent parity-related posts. This leads into a brief discussion of...

Mind-Body Dualism. Why are there different rules for brain stuff than for body stuff? Isn't the brain part of the body? Will we still be having this debate in yet another 2400 years?

Pink Floyd's Syd Barrett. Brief mention of my post last month, Shine On, You Crazy Diamond, which, in turn, points to the "Images in Psychiatry" section of the July, 2007, issue of AJP, a tribute written by Paolo Fusar-Poli. "Nobody knows where you are, How near or how far."

Three articles on suicide in the July 2007 AJP. The first, by Simon & Savarino, is a well-done study looking at the relationship between the initiation of depression treatment (medication or psychotherapy) and suicide attempts by looking at outpatient insurance claims of a half-million members. They found that suicide attempt rates were highest in the month before treatment initiation, and that the patterns were similar for medications and psychotherapy. See below image. Most of the people (some 90% or so) were being treated by their primary care physicians. Those with the highest risk appeared to have been referred on to therapists or psychiatrists. Regardless (and not surprisingly), the patterns were the same. As stated by David Brent in his editorial, "it is much more likely that suicidal behavior leads to treatment than that treatment leads to suicidal behavior."

The next podcast, or podette, will be a brief one (for us) which I will post this weekend (yes, two podcasts in as many days... we have to make up for lost time somehow) prior to our next regular podcast, which we will record on Aug 19, probably between 3-5 pm ET. If any other psychiatrist listeners can join in at that time via Skype or Talkshoe, let us know and we might include you as a guest on the show.

S . 558 . A bill to provide parity between health insurance coverage of mental health benefits and benefits for medical and surgical services; to the Committee on Health, Education, Labor, and Pensions.

Mr. KENNEDY. Access to mental health services is one of the most important and most neglected civil rights issues facing the Nation. For too long, persons living with mental disorders have suffered discriminatory treatment at all levels of society. They have been forced to pay more for the services they need and to worry about their job security if their employer finds out about their condition. Sadly, in America today, patients with biochemical problems in their liver are treated with better care and greater compassion than patients with biochemical problems in their brain.

That kind of discrimination must end. No one questions the need for affordable treatment of physical illnesses. But those who suffer from mental illnesses face serious barriers in obtaining the care they need at a cost they can afford. Like those suffering from physical illnesses, persons with mental disorders deserve the opportunity for quality care. The failure to obtain treatment can mean years of shattered dreams and unfulfilled potential.

Eleven years ago, Congress passed the first Mental Health Parity Act. That legislation was an important first step in bringing attention to discriminatory practices against the mentally ill, but it did little to correct the injustices that so many Americans continue to face. The 1996 legislation required that annual and lifetime dollar limits for mental health coverage must be no less than the limits for medical and surgical coverage. But more steps are clearly needed to guarantee that Americans suffering from mental illness are not forced to pay more for the services they need, do not face harsher limitations on treatment, and are not denied access to care.

This bill is a chance to take the actions needed to end the longstanding discrimination against persons with mental illness. The late Senator Paul Wellstone and Senator Pete Domenici deserve great credit for their bipartisan leadership on mental health parity. If it were not for them, we would not be here today.

The bill prohibits group health plans from imposing treatment limitations or financial requirements on the coverage of mental health conditions that do not also apply to physical conditions. That means no limits on days or treatment visits, and no exorbitant co-payments or deductibles. The bill was negotiated by and has the support of the mental health community, the business community, and the insurance industry.

The need is clear. One in five Americans will suffer some form of mental illness this year--but only a third of them will receive treatment. Millions of our fellow citizens are unnecessarily enduring the pain and sadness of seeing a family member, friend, or loved one suffer illnesses that seize the mind and break the spirit.

Battling mental illness is itself a painful process, but discrimination against persons with such illnesses is especially cruel, since the success rates for treatment often equal or surpass those for physical conditions. According to the National Institute of Mental Health, clinical depression treatment can be 70 percent successful, and treatment for schizophrenia can be 60 percent successful.

Over the years we've heard compelling testimony from experts, activists, and patients about the need to equalize coverage of physical and mental illnesses. The Office of Personnel Management talks us that providing full parity to 8.5 million federal employees has led to minimal premium increases. We heard dramatic testimony about the economic and social advantages of parity, including a healthier, more productive workforce.

Some of the most compelling testimony came several years ago from Lisa Cohen, a hardworking American from New Jersey, who suffers from both physical and mental illnesses, and is forced to pay exorbitant costs for treating her mental disorder, while paying little for her physical disorder. She is typical of millions of Americans who not only face the cruel burden of mental illness, but also the cruel burden of discriminatory treatment. No Americans should be denied equal treatment of an illness because it starts in the brain instead of the heart, lungs, or other parts of their body. No patients should be denied access to the treatment that can cure their illness because of where they live or work.

A number of States have already enacted mental health parity laws, but 86 million workers under ERISA have no protection under state mental health statutes.

Mental health parity is a good investment for the Nation. The costs from lost worker productivity and extra physical care outweigh the costs of implementing parity for mental health treatment.

Over the years study after study has shown that parity makes good financial sense. An analysis of more than 46,000 workers at major companies showed that employees who report being depressed or under stress are likely to have substantially higher health costs than co-workers without such conditions. Employees who reported being depressed had health bills 70 percent higher than those who did not suffer from depression. Those reporting high stress had 46 percent higher health costs. McDonnell Douglas found a 4 to 1 return on investment after accounting for lower medical claims, reduced absenteeism, and smaller turnover.

Mental illness also imposes a huge financial burden on the Nation. It costs us $300 billion each year in treatment expenses, lost worker productivity, and crime. This country can afford mental health parity. What we can't afford is to continue denying persons with mental disorders the care they need.

Today is a turning point. We are finally moving toward ending this shameful form of discrimination in our society--discrimination against mental illness. This bill has been seven years in the making, and brings first class medicine to millions of Americans who have been second class patients for too long.

Today, we begin to right that wrong, by guaranteeing equal treatment to the 11 million people receiving mental health services, and promising equal treatment to the remaining 100 million insured workers and their families who never know the day they may need their mental health benefit.

The 1996 Act, was an important step towards ending health insurance discrimination against mental illness. This bill will take another large step forward by closing the loopholes that remain.

It guarantees co-payments, deductibles, coinsurance, out of pocket expenses and annual and lifetime limits that apply to mental health benefits are no different than those applied to medical and surgical benefits.

It guarantees that the frequency of treatment, number of visits, days of coverage and other limits on scope and duration of treatment for mental health services are no different than those applied to medical and surgical benefits.

This equal treatment and financial equity is also applied to substance abuse.

Features of State law that require coverage of mental disorders are protected, to assure those currently protected by state parity laws that their needs will be met.

Finally, the bill is modeled on the parity that is already guaranteed to the 8.5 million persons, including Members of Congress, under the Federal Employee Benefits Program,

Equal treatment of those affected by mental illness is not just an insurance issue. It's a civil rights issue. At its heart, mental health parity is a question of simple justice.

It is long past time to end insurance discrimination and guarantee all people with mental illness the coverage they deserve.

I urge my colleagues to support this important principle, and end the unacceptable double standards that have unfairly plagued our health care systems for so long.

Mr. DOMENICI. Mr. President, I rise today along with my colleagues Senator Kennedy and Senator Enzi to introduce the Mental Health Parity Act of 2007. I want to thank my colleagues for all of their hard work on this issue and I am glad we are able to introduce this paramount legislation.

Simply put, our legislation will provide parity between mental health coverage and medical and surgical coverage. No longer will people be treated differently only because they suffer from a mental illness. This means 113 million people in group health plans will benefit from our bill.

We are here today after years of hard work. We have worked with the mental health community, the business community, and insurance groups to carefully construct a fair bill. A sampling of the groups include the National Alliance on Mental Illness, the American Psychological Association, the American Psychiatric Association, the National Retail Federation, and Aetna Insurance.

This bill will no longer apply a more restrictive standard to mental health coverage and another more lenient standard be applied to medical and surgical coverage. What we are doing is a matter of simple fairness. Statistics demonstrate that there is a significant need for this change in policy. Currently, 26 percent of American adults or nearly 58 million people suffer from a diagnosable mental illness each year. Six percent of those adults suffer from a serious mental illness. Additionally, more than 30,000 people commit suicide each year in the United States. We need to reduce these numbers, and I believe expanding access to mental health services will allow us to do so.

This bill will provide mental health parity for about 113 million Americans who work for employers with 50 or more employees and ensure health plans do not place more restrictive conditions on mental health coverage than on medical and surgical coverage. Additionally, the legislation includes parity for financial requirements such as deductibles, copayments, and annual lifetime limits. Also, this bill includes parity for treatment limitations regarding the number of covered hospital days and visits. This bill does not Mandate the coverage of mental health nor does it prohibit a health plan from managing mental health benefits in order to ensure only medically necessary treatments are covered.

Again, I would like to thank everyone who contributed to the development of this legislation. I believe we are making a difference today and I look forward to working with my colleagues to move this bill forward.

I ask for unanimous consent that the text of the bill to be printed in the Record.

There being no objection, the text of the bill was ordered to be printed in the Record, as follows:

Here is the text of the bill:

S . 558

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ``Mental Health Parity Act of 2007''.

SEC. 2. MENTAL HEALTH PARITY.

(a) Amendments of ERISA.--Subpart B of part 7 of title I of the Employee Retirement Income Security Act of 1974 is amended by inserting after section 712 (29 U.S.C. 1185a) the following:

``SEC. 712A. MENTAL HEALTH PARITY.

``(a) In General.--In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health benefits, such plan or coverage shall ensure that--

``(1) the financial requirements applicable to such mental health benefits are no more restrictive than the financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), including deductibles, copayments, coinsurance, out-of-pocket expenses, and annual and lifetime limits, except that the plan (or coverage) may not establish separate cost sharing requirements that are applicable only with respect to mental health benefits; and

``(2) the treatment limitations applicable to such mental health benefits are no more restrictive than the treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage), including limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment.

``(b) Clarifications.--In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health benefits, such plan or coverage shall not be prohibited from--

``(1) negotiating separate reimbursement or provider payment rates and service delivery systems for different benefits consistent with subsection (a);

``(2) managing the provision of mental health benefits in order to provide medically necessary services for covered benefits, including through the use of any utilization review, authorization or management practices, the application of medical necessity and appropriateness criteria applicable to behavioral health, and the contracting with and use of a network of providers; or

``(3) applying the provisions of this section in a manner that takes into consideration similar treatment settings or similar treatments.

``(c) In- and Out-of-Network.--

``(1) IN GENERAL.--In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health benefits, and that provides such benefits on both an in- and out-of-network basis pursuant to the terms of the plan (or coverage), such plan (or coverage) shall ensure that the requirements of this section are applied to both in- and out-of-network services by comparing in-network medical and surgical benefits to in-network mental health benefits and out-of-network medical and surgical benefits to out-of-network mental health benefits, except that in no event shall this subsection require the provision of out-of-network coverage for mental health benefits even in the case where out-of-network coverage is provided for medical and surgical benefits.

``(2) CLARIFICATION.--Nothing in paragraph (1) shall be construed as requiring that a group health plan (or coverage in connection with such a plan) eliminate an out-of-network provider option from such plan (or coverage) pursuant to the terms of the plan (or coverage).

``(d) Small Employer Exemption.--

``(1) IN GENERAL.--This section shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) for any plan year of any employer who employed an average of at least 2 (or 1 in the case of an employer residing in a State that permits small groups to include a single individual) but not more than 50 employees on business days during the preceding calendar year.

``(2) APPLICATION OF CERTAIN RULES IN DETERMINATION OF EMPLOYER SIZE.--For purposes of this subsection:

``(A) APPLICATION OF AGGREGATION RULE FOR EMPLOYERS.--Rules similar to the rules under subsections (b), (c), (m), and (o) of section 414 of the Internal Revenue Code of 1986 shall apply for purposes of treating persons as a single employer.

``(B) EMPLOYERS NOT IN EXISTENCE IN PRECEDING YEAR.--In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.

``(C) PREDECESSORS.--Any reference in this paragraph to an employer shall include a reference to any predecessor of such employer.

``(e) Cost Exemption.--

``(1) IN GENERAL.--With respect to a group health plan (or health insurance coverage offered in connections with such a plan), if the application of this section to such plan (or coverage) results in an increase for the plan year involved of the actual total costs of coverage with respect to medical and surgical benefits and mental health benefits under the plan (as determined and certified

[Page: S1866] GPO's PDFunder paragraph (3)) by an amount that exceeds the applicable percentage described in paragraph (2) of the actual total plan costs, the provisions of this section shall not apply to such plan (or coverage) during the following plan year, and such exemption shall apply to the plan (or coverage) for 1 plan year. An employer may elect to continue to apply mental health parity pursuant to this section with respect to the group health plan (or coverage) involved regardless of any increase in total costs. ``(2) APPLICABLE PERCENTAGE.--With respect to a plan (or coverage), the applicable percentage described in this paragraph shall be--

``(A) 2 percent in the case of the first plan year in which this section is applied; and

``(B) 1 percent in the case of each subsequent plan year.

``(3) DETERMINATIONS BY ACTUARIES.--Determinations as to increases in actual costs under a plan (or coverage) for purposes of this section shall be made by a qualified actuary who is a member in good standing of the American Academy of Actuaries. Such determinations shall be certified by the actuary and be made available to the general public.

``(4) 6-month DETERMINATIONS.--If a group health plan (or a health insurance issuer offering coverage in connections with a group health plan) seeks an exemption under this subsection, determinations under paragraph (1) shall be made after such plan (or coverage) has complied with this section for the first 6 months of the plan year involved.

``(5) NOTIFICATION.--An election to modify coverage of mental health benefits as permitted under this subsection shall be treated as a material modification in the terms of the plan as described in section 102(a)(1) and shall be subject to the applicable notice requirements under section 104(b)(1).

``(f) Rule of Construction.--Nothing in this section shall be construed to require a group health plan (or health insurance coverage offered in connection with such a plan) to provide any mental health benefits.

``(g) Mental Health Benefits.--In this section, the term `mental health benefits' means benefits with respect to mental health services (including substance abuse treatment) as defined under the terms of the group health plan or coverage.''.

(b) Public Health Service Act.--Subpart 1 of part A of title XXVII of the Public Health Service Act is amended by inserting after section 2705 (42 U.S.C. 300gg-5) the following:

``SEC. 2705A. MENTAL HEALTH PARITY.

``(a) In General.--In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health benefits, such plan or coverage shall ensure that--

``(1) the financial requirements applicable to such mental health benefits are no more restrictive than the financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), including deductibles, copayments, coinsurance, out-of-pocket expenses, and annual and lifetime limits, except that the plan (or coverage) may not establish separate cost sharing requirements that are applicable only with respect to mental health benefits; and

``(2) the treatment limitations applicable to such mental health benefits are no more restrictive than the treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage), including limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment.

``(b) Clarifications.--In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health benefits, such plan or coverage shall not be prohibited from--

``(1) negotiating separate reimbursement or provider payment rates and service delivery systems for different benefits consistent with subsection (a);

``(2) managing the provision of mental health benefits in order to provide medically necessary services for covered benefits, including through the use of any utilization review, authorization or management practices, the application of medical necessity and appropriateness criteria applicable to behavioral health, and the contracting with and use of a network of providers; or

``(3) be prohibited from applying the provisions of this section in a manner that takes into consideration similar treatment settings or similar treatments.

``(c) In- and Out-of-Network.--

``(1) IN GENERAL.--In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health benefits, and that provides such benefits on both an in- and out-of-network basis pursuant to the terms of the plan (or coverage), such plan (or coverage) shall ensure that the requirements of this section are applied to both in- and out-of-network services by comparing in-network medical and surgical benefits to in-network mental health benefits and out-of-network medical and surgical benefits to out-of-network mental health benefits, except that in no event shall this subsection require the provision of out-of-network coverage for mental health benefits even in the case where out-of-network coverage is provided for medical and surgical benefits.

``(2) CLARIFICATION.--Nothing in paragraph (1) shall be construed as requiring that a group health plan (or coverage in connection with such a plan) eliminate an out-of-network provider option from such plan (or coverage) pursuant to the terms of the plan (or coverage).

``(d) Small Employer Exemption.--

``(1) IN GENERAL.--This section shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) for any plan year of any employer who employed an average of at least 2 (or 1 in the case of an employer residing in a State that permits small groups to include a single individual) but not more than 50 employees on business days during the preceding calendar year.

``(2) APPLICATION OF CERTAIN RULES IN DETERMINATION OF EMPLOYER SIZE.--For purposes of this subsection:

``(A) APPLICATION OF AGGREGATION RULE FOR EMPLOYERS.--Rules similar to the rules under subsections (b), (c), (m), and (o) of section 414 of the Internal Revenue Code of 1986 shall apply for purposes of treating persons as a single employer.

``(B) EMPLOYERS NOT IN EXISTENCE IN PRECEDING YEAR.--In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.

``(C) PREDECESSORS.--Any reference in this paragraph to an employer shall include a reference to any predecessor of such employer.

``(e) Cost Exemption.--

``(1) IN GENERAL.--With respect to a group health plan (or health insurance coverage offered in connections with such a plan), if the application of this section to such plan (or coverage) results in an increase for the plan year involved of the actual total costs of coverage with respect to medical and surgical benefits and mental health benefits under the plan (as determined and certified under paragraph (3)) by an amount that exceeds the applicable percentage described in paragraph (2) of the actual total plan costs, the provisions of this section shall not apply to such plan (or coverage) during the following plan year, and such exemption shall apply to the plan (or coverage) for 1 plan year. An employer may elect to continue to apply mental health parity pursuant to this section with respect to the group health plan (or coverage) involved regardless of any increase in total costs.

``(2) APPLICABLE PERCENTAGE.--With respect to a plan (or coverage), the applicable percentage described in this paragraph shall be--

``(A) 2 percent in the case of the first plan year in which this section is applied; and

``(B) 1 percent in the case of each subsequent plan year.

``(3) DETERMINATIONS BY ACTUARIES.--Determinations as to increases in actual costs under a plan (or coverage) for purposes of this section shall be made by a qualified actuary who is a member in good standing of the American Academy of Actuaries. Such determinations shall be certified by the actuary and be made available to the general public.

``(4) 6-month DETERMINATIONS.--If a group health plan (or a health insurance issuer offering coverage in connections with a group health plan) seeks an exemption under this subsection, determinations under paragraph (1) shall be made after such plan (or coverage) has complied with this section for the first 6 months of the plan year involved.

``(5) NOTIFICATION.--An election to modify coverage of mental health benefits as permitted under this subsection shall be treated as a material modification in the terms of the plan as described in section 102(a)(1) and shall be subject to the applicable notice requirements under section 104(b)(1).

``(f) Rule of Construction.--Nothing in this section shall be construed to require a group health plan (or health insurance coverage offered in connection with such a plan) to provide any mental health benefits.

``(g) Mental Health Benefits.--In this section, the term `mental health benefits' means benefits with respect to mental health services (including substance abuse treatment) as defined under the terms of the group health plan or coverage, and when applicable as may be defined under State law when applicable to health insurance coverage offered in connection with a group health plan.''.

SEC. 3. EFFECTIVE DATE.

(a) In General.--The provisions of this Act shall apply to group health plans (or health insurance coverage offered in connection with such plans) beginning in the first plan year that begins on or after January 1 of the first calendar year that begins more than 1 year after the date of the enactment of this Act.

(b) Termination of Certain Provisions.--

(1) ERISA.--Section 712 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185a) is amended by striking subsection (f) and inserting the following:

``(f) Sunset.--This section shall not apply to benefits for services furnished after the effective date described in section 3(a) of the Mental Health Parity Act of 2007.''.

(2) PHSA.--Section 2705 of the Public Health Service Act (42 U.S.C. 300gg-5) is amended by striking subsection (f) and inserting the following:

[if there was more, I couldn't find it...]===========================================================

Thursday, August 16, 2007

I've been following the discussion between Roy, Dinah and Anonymous Commenter regarding Dr. Melfi's treatment of Tony Soprano. Yeah, it's just a TV show. No, I'm not obsessed or preoccupied with any of the characters. It's brought up an interesting question and a few ethical issues though. I will apologize in advance if I've misquoted or misattributed any opinions; I'm writing this off the top of my head and I'm not going to claim to be able to remember exactly who said what.

Anyway, Anonymous Commenter wondered why Dr. Melfi was treating Tony Soprano at all given his antisocial involvements and the potential risk he might present to Dr. Melfi's other patients. There was a suggestion that 'evil' could not be cured, and that a certain amount of psychological symptomatology is the natural result of involvement in criminal activity. There was some discussion about whether or not it was fair or appropriate to allow criminals to live with their symptoms, medical or otherwise.

As a forensic and correctional psychiatrist I find it interesting that these questions are being asked.

When people have brain diseases, they deserve treatment. People deserve to be healthy. When I had pneumonia last January I didn't have to give a justification for wanting to be well, and I wouldn't expect that from my offender patients either. The treatment of offenders does get a bit complicated since some of them do present significant safety risks to those around them; some can only be treated in a secure environment. The tricky part, as I believe Dinah or Roy mentioned, is that you don't always know who you have in your office when they first walk in the door. The true level pathology is not always evident until after you've already engaged the person in treatment.

The next question is whether or not 'evil' can be cured. If not, why attempt treatment? As Anonymous Commenter correctly pointed out, 'evil' is a tricky term. It falls outside the realm of medicine and carries quite a boatload of value-laden judgement. There are behaviors that all would agree are so far outside the realm of compassion that most people would consider them evil. On the other hand, one could make the argument that non-violent criminal activity which harms large numbers of people (eg. Enron and the financial devestation of shareholders) is evil.

Regardless, the real question is whether or not psychotherapy can prevent criminal recidivism the answer to that would be no. I blogged about Maryland's experiment with therapeutic prisons a long time ago in Couch Time. The followup from that experience showed that, at best, therapy did not make offenders worse.

Psychotherapy does help offenders for other issues, though, in the same way that it helps non-criminals. Prisoners are people who need help adjusting to incarceration, people who have family losses or crises, people who are dealing with serious medical illnesses. Crisis intervention and supportive counselling is invaluable for this. And yes, even Tony Soprano deserves it.

Okay, folks, I'm back and refreshed and will put up the podcast we did a few weeks ago later on today (I thought about posting it while hanging out at the campsite, but -- and I hate to say it -- it felt too much like "work") .

BTW, two of the four campgrounds (as in tents, mind you, not hulking Winnebagos) we stayed at had Wi-Fi... not sure if this is good or bad.

Just wanted to be sure you noticed that this week's Grand Rounds is over at Med Journal Watch. Christian did a great job with it (apologies for not keeping the Grand Rounds link in our header current while I was away).

Also wanted to point you to a very thoughtful and useful post from Jayme over at Rayne's World, called How I Deal with Mental Breakdowns. Very well done (and check out her amazing drawings... hint: they are NOT black&white photos).

Wednesday, August 15, 2007

I started to write a reply to Jayme, who commented on my post Shrinks Aren't Perfect, then I realized the answer was its own post.

Jayme wrote:

I am having a hard time empathizing with psychiatrists being falsely portrayed in the media when psych patients are portrayed far worse, more often, and with incredibly damaging consequences. I don't see much discrimination against psychiatrists because of bad media portrayals. I'd really like to see you gripe about society's lack of empathy toward psych patients instead of your own. I hope this is taken with the spirit it was intended. Thank you.

Absolutely, I agree that the media portrayal of people with psychiatric disorders is awful and stigmatizing. I don't really care how the media portrays psychiatrists for my own sake--I make a living, I have a blog, what more could I want? I knew the profession carried stigma when I chose it, and I chose it. People don't choose to get mental illnesses. The media tends to portray the mentally ill in ways that obliterate any other aspect of their being. Often psychiatric patients are depicted as weird, creepy, or outright dangerous.

The psychiatric setting is used in media for 1) the entertainment value complete with distortions and 2) in terms of story development, the setting can often provide insights/information into a character that couldn't be gleaned in other ways--though this is more true in terms of written/literary plots where point of view limits access to information.

The issue of portraying the psychiatrist negatively is not one that means much to me-- face it, some psychiatrists are pretty weird. I may be pretty weird. The issue of portraying psychiatry in a negative light is that it creates a negative aura around mental health care delivery which spreads out to include the patient, it fosters the stigma, and it makes people with problems hesitant to seek care. You're going to go see a psychiatrist? Shrinks are so messed up themselves, how can they help you? You're doc might turn out to be Hannibal Lechter (pass the Chianti, please) or that transvestite serial killer from Dressed to Kill. Or maybe he'll just be twitchy and pompous like Niles Crane on Frasier.

In the movies, psychiatric patients aren't normal people living normal lives who either get overwhelmed with their problems or get afflicted with a mental illness, who then see a doc and get helpful treatment from a kind and caring person. There's nothing about what one sees on TV or in the movies that would make you want to see shrink.

An "Anonymous" commenter has been kind enough to provide the reference to the Letter I read in Psychiatric Times: The author is Harvey Roy Greenberg (not of Shrink Rap) and Anon writes:

Re: Dr Melfi. The guy who has the same middle name as your co-blogger did not write that she sometimes made mistakes or failed to be empathic all the time. He wrote that her treatment was riddled with EGREGIOUS mistakes and that at times she betrayed a STARTLING lack of empathy. Never watched the show, can't say what she did or didn't do,but there are mistakes and then there are mistakes. No shrink can be empathic all the time but when it comes to a STARTLING lack, then that shrink should refer or the patient should run. Shrinks everywhere: please try to remember that this is a TV character. It is wacko to get this connected with a TV character. As for Beautiful Mind, the ECT and other treatment depicted therein date back many years. If someone suggests that their patients watch it they might also add that disclaimer. This other Roy guy was not writing about you, but you sure took it personally and your reaction seems way out of whack with the provocation. I'm just not getting it.

The Sopranos is different from other media portrayals of psychiatry. Yes, I know it's a TV show, and yes, I've seen every episode (thanks to Blockbuster and HBO on DVDs). Tony Soprano is a nice normal Mafia boss, he "works," he loves, he functions as a Mafia boss will function, and he seeks psychiatric care because he starts having panic attacks. He may be evil, but he's not crazy, and his mental illness is a small part of who he is and what he does. He is a difficult patient-- he steals his doctor's car to have it repaired, he declares his love for her, he sends her flowers, he curses her out and leaves, he has affair with a woman he meets in her waiting room and that patient commits suicide after Tony ends the affair. The list goes on. We also get to see Dr. Melfi's therapy/supervision sessions so we have some insight into just how conflicted she is about treating Tony. Off hand, without reviewing every episode, I don't recall any Egregious errors. I guess the question might be asked, What would be an egregious error in psychotherapy? Dr. Greenberg is a psychoanalyst, perhaps his idea of an error is different than mine? A Startling lack of empathy? There are moments when it would be startlingly difficult to empathize with Tony--especially as a woman listening to his continued sexual indiscretions. Sympathy? Well maybe, but Empathy? He spares Dr. Melfi the details of his violent life--in the first season he talks about working out difficulties with an adversary where he cages running the guy down and breaking his legs as "We had coffee."

Finally-- Roy is back soon, and our regular podcast schedule will resume shortly.

Tuesday, August 14, 2007

Oh, gosh, I got home and realized I don't have my reference. I was reading Psychiatric Times today and came across a letter to the editor. All I remember is that the writer's middle name was Roy, though not of Shrink Rap.

So apparently there was an article that said the media was getting better about their portrayals of psychiatry. The middle-named-Roy guy (not of Shrink Rap) wrote in to say that he disagreed, that medial portrayals are not getting better. He cited the movie A Beautiful Mind as being an unfavorable and inaccurate view of our profession. He noted that fictional psychiatrist Dr. Jennifer Melfi of The Sopranos is held up as a realistic TV psychiatrist but, he said, she makes mistakes and often lacks empathy.

I have a confession to make. Sometimes I make mistakes and sometimes I lack empathy. I try to be understanding. sympathetic, to bounce back a patient's emotional life in words that make them feel understood-- really this is the meat of therapy. Sometimes, people describe to me reactions that just don't resonate with me--- in the situation they are describing, I just wouldn't feel the way they feel. If it's a huge disconnect, I ask more questions, get more detail, but sometimes I just can't get on the same page. This is particularly true when people talk about having literally violent reactions to minor provocations, just to give an example. And there are times when it's clear I've simply said the wrong thing-- if it's obvious by the look on the patient's reaction, I try to address it, but sometimes people feel injured and it's not apparent until much later.

Dr. Melfi makes mistakes. At times, she lacks empathy. No wonder I like her so much.

Saturday, August 11, 2007

This one's been simmering in my brain for a while. With our sidebar voters telling us they like psychotherapy posts, I figured it was a good time.

So my very confabulated patient comes to therapy in a state of acute distress. His wife died unexpectedly only weeks before; he is tearful, angry, and sad with heart-wrenching poignance. He's lost his appetite, he pines for her, he misses her and sometimes things as trivial as a commercial she'd commented on will make him burst into tears. On the flip side, he's back at work, taking care of his kids and their needs, and while he's distraught, he's not feeling guilty or suicidal or having anything very strange happen. He has no history of psychiatric disorder and he has a lot of support from family and friends. While everyone is concerned and trying to help him cope, no one has commented that his reaction to this tragic event is any thing other than what one might expect. In a word, the patient is grieving.

Acute grief alone is not usually a reason people seek psychiatric treatment. I listen, I offer some reassurances, and while I'm happy to be there for him, there is not much to do. Time will help. Time will help a lot, but it may take a lot of time.

"What made you feel you needed to see a psychiatrist?" I asked. I tried to say it gently, not as What You Doing Here? but simply as a question of Is There More To This?

"Losing my wife," he said, "Has brought up some old stuff for me."

His stories poured out. It was a difficult one with lots of early losses, family chaos with some periods in foster care, neglect and abuse. A lot of struggles, and a lot of room to create psychopathology. But there was none-- this was a man who owned his own business, had devoted employees and friends, a single marriage of many years, children of whom he was proud, in short-- a full and functional life. That's not to say there hadn't been hard times or that he'd never struggled as an adult, or even that life was perfect, but he didn't have a mental illness and he was able to love, work, and sustain meaningful relationships.

The question, I thought, and maybe I even said it, wasn't why this man was having problems now, it was why hadn't he had problems before.

"You've had a lot to deal with, " I said (--that's about as profound as I get).

"Yeah, but what can you do? I'm not much for dwelling in the past, but lately, I've been thinking about this stuff again."

He's right, of course, that if one can put the past aside and deal with life as it comes, that's better. It's when the past gets in the way of the present and future, or when the patient just can't move on, that it becomes mandatory to explore it in therapy. I'm left to wonder, though, why some people are crippled by stories that don't sway so far from the norm of what life deals, and others soar after enduring the extremes.

He came for a while, told his stories, grieved intensely. Mostly I listened, often I wanted to cry myself.

Wednesday, August 08, 2007

One month ago today I posted the Who Reads Shrink Rap? poll on our sidebar. We know we get roughly 1500 unique visitors a week, but people aren't much for polls. We took guesses, we even set up a poll to see who folks wanted to win the guess about how many people would actually take our poll (say what?). I guessed we'd have 275 responses, ClinkShrink said 186, Roy said 246. With 251 responses, Roy is both the closest and he hasn't gone over. You Go, Roy!

Tuesday, August 07, 2007

Oh deer...er, dear. It's been three weeks since my last blog post. I have a good excuse. I was having fun.

Rushing mountain water is very cold. Standing on the top of a mountain as a lightening storm rolls in is rather impressive. I enjoyed watching a hawk in flight and waking up in the middle of the night as some type of wildlife rummaged through the campsite. I even enjoyed the hailstorm, except for maybe the part about wondering whether the tent would be gone when it was all over. I saw loads of deer (including the one that rummaged through the campsite), a bear (it looked at me and was obviously sniffing for beef jerky. Fortunately I wasn't the one carrying it.), lots of cold rushing water and water falls, and even a skunk (see reduced picture).

My favorite find was this very unusual looking mushroom.

It was huge as well as being a bright yellow-orange color. After a bit of Googling I think I've got it identified, but if any of you out there really know mushrooms and can tell me for sure I'd appreciate it. I think it's a jack o'lantern mushroom (omphalotus illudens) which is known to be toxic. Somehow it seemed rather fitting that poisonous plants should be part of a forensic psychiatrist's vacation experience. There were no historical prisons in the mountains, so I had to find something forensically relevant.